IPSRT
Interpersonal social rhythm therapy
-interpersonal with social rhythm aspects
-interpersonal changes in a person’s life with circadian rhythm disturbances can lead to relapse
-interpersonal: addresses role transitions, role disputes, interpersonal deficits or grief e.g. losing independence
-social rhythm: maintaining a routine e.g. sleep wake cycle, mealtimes
Reasons for stopping psychotherapy
Personal factors
-cultural alternate explanatory models of illness
-language barriers
-stigma towards mental illness
-negative attitudes to western models of mental illness
-belief in alternative or culturally different MH treatments
-presence of MI with sx impeding engagement (fatigue, cognitive slowing, depression)
Psychotherapy factors
-ineffective psychotherapy
-poor therapeutic relationship
-cultural and language sensitivity not taken
-gender sensitivity barriers
-side effects e.g. worsening depression, anxiety, insomnia
System factors
-travel
-cost
-unable to leave child
Cluster A PD
- Paranoid personality disorder: irrational suspicions and mistrust of others
- Schizoid personality disorder: lack of interest in social relationships, seeing no point in sharing time with others, anhedonia, introspection
- Schizotypal personality disorder: odd behaviour or thinking
Cluster B PD
- Antisocial personality disorder: pervasive disregard for the law and the rights of others
- Borderline personality disorder: extreme ‘black and white’ thinking,
instability in relationships, self-image, identity and behaviour, often leading to self-harm and impulsivity - Histrionic personality disorder: pervasive attention-seeking behaviour,
including inappropriately seductive behaviour and shallow or exaggerated emotions - Narcissistic personality disorder: pervasive pattern of grandiosity, need for admiration, and a lack of empathy
Cluster C PD
- Avoidant personality disorder: social inhibition, feelings of inadequacy,
extreme sensitivity to negative evaluation and avoidance of social interaction - Dependent personality disorder: pervasive psychological dependence on other people
- Obsessive–compulsive personality disorder: rigid conformity to rules,
moral codes and excessive orderliness
Pathogenesis of PD
- Impact of external events on neurobiological development and gene-environment interactions
-being raised in hostile or abusive environment - Social attachment over time
-BPD: preoccupied or enmeshment attachment where individual is highly ambivalent about those to whom they are attached ( in a passive and/or angry way) - Persistence of childhood thinking/feeling patterns
-collection of immature defences
PD diagnostic instruments
Minnesota Multiphasic Personality Inventory-II:
selfreport measure of global psychopathology consisting of 567 true/false items giving information about symptoms and interpersonal relationships
Staff issues that arise with PD
- Tensions between personal and professional identities
- The pull to punish: bullying, intimidation and assaults on patients by staff have been associated with circumstances in which there are no safeguards on imbalances of power
- Displacement, ‘acting out’ of distress and Splitting
- Complex and damaging repetitions: Staff actions/interpersonal styles
often trigger such conflict re-enactments through the process of ‘projective identification’ - Boundary Violations
Features of OCD psychological plan (RANZCP)
PSYCHOEDUCATION:
* Provide information to the patient and family about the condition in a way that has personal relevance.
* Provide information that exposure and response prevention, and cognitive therapy have the best evidence base.
* Explain rationale of chosen psychological treatment.
COGNITIVE BEHAVIOUR THERAPY:
* Initial assessment and formulation, assess preparedness to change; identify maintaining factors: triggers, avoidance and safety behaviours.
* Development of exposure hierarchy. Use of a measurable monitor of change, e.g. Subjective Units of Distress Scale, YBOCS, or other.
* Choose goals to work on and set specific homework tasks.
* Confront each chosen situation, refrain from engaging in compulsive ritual and stay in situation until anxiety subsides.
* Monitor using an appropriate outcome measurement e.g. role of Goal Attainment Scale.
FAMILY INTERVENTION:
* Family therapy to support understanding of and responses to enduring patterns.
* Negotiate role for parents; practical advice for parents assisting them not to inadvertently do things for him instead of with him
e.g. by completing tasks for him.
* Identify the dynamics/parental responses which may be reinforcing the illness, e.g. conflict avoidance.
LONG TERM RECOVERY:
* Maximising quality of life even in the context of chronic disorder, including vocational and functional rehabilitation.
* Learning to live with OCD.
* Identifying and encouraging realistic goals.
CBT for GAD
- Education about worrying, factors that facilitate or hinder therapy. Recommended exercise, no D&A
- Progressive muscle relaxation and breathing training to improve physical
symptoms as well as reducing cognitive symptoms to challenge unhelpful thinking.
Behaviour avoidance using graded exposure - Relapse prevention, identification of EWS, future goal setting
CBT for panic disorder
- Education on anxiety/panic disorder and rationale for treatment. Identify factors that can facilitate therapy such as future education of family and supports
- Behavioural experiments that can challenge a patient to identify catastrophic cognitions that hinder therapy. Patients are required to identify and reduce feared physical sensations and avoidance behaviours that the patient uses to prevent panic-related situations.
- Structured to prevent relapse by identifying what may precipitate a relapse and strategising how the patient can manage these situations.
Components of DBT
Individual sessions
* Last for 45–60 minutes and occur weekly.
* Life-threatening behaviours
* Therapy-interfering behaviours
* Quality-of-life-interfering behaviours
* Attention to skills.
Skills training group
* Skills training is conducted in a weekly group, which typically lasts for 2 or 2
hours.
* The style of the group is didactic.
* The skills training is organised around a manual that sets out the content of the
programme in detail and gives advice about how it should be taught (Linehan, 1993b).
Four modules
a. Emotional regulation
b. Distress tolerance
c. Interpersonal effectiveness
d. Mindfulness
Out-of-hours telephone contact
* Brief, 5–10 minutes
* To help the patient avoid self-harm
* Planned contract between patient and therapist
The consultation group
* Team – the individual therapists and skills trainers – meet to review the programme
and their practice.
Family therapy in Scz
- Family psychoeducation
- Building a therapeutic alliance with the family
- Address high EE
- Increase problem solving capacity of family
- Enhancing communication through circular questioning
- Boundary setting
Promoting individual independence - Allowing venting of anger and frustration
- Involving family in relapse prevention
Adherence therapy
- Reflective listening
- Regular summarising
- Inductive questioning
- Exploring ambivalence
- Use normalising rationales
Motivational Interviewing
- Express empathy
- Develop discrepancy
- Support self-efficacy
-Engaging: This is the foundation of MI. The goal is to establish a productive working relationship through careful listening to understand and accurately reflect the person’s experience and perspective while affirming strengths and supporting autonomy.
-Focusing: In this process an agenda is negotiated that draws on both the client and practitioner expertise to agree on a shared purpose, which gives the clinician permission to move into a directional conversation about change.
-Evoking: In this process the clinician gently explores and helps the person to build their own “why” of change through eliciting the client’s ideas and motivations. Ambivalence is normalized, explored without judgement and, as a result, may be resolved. This process requires skillful attention to the person’s talk about change.
-Planning: Planning explores the “how” of change where the MI practitioner supports the person to consolidate commitment to change and develop a plan based on the person’s own insights and expertise. This process is optional and may not be required, but if it is the timing and readiness of the client for planning is important.
in PTSD
Cognitive behavioural therapy
* Cognitive behaviour therapy in ASD or PTSD targets the distorted threat appraisal
process (in some instances through repeated exposure and in others through
techniques focusing on information processing without repeated exposure) in an effort
to desensitise the patient to trauma-related triggers.
EMDR
* EMDR is a form of psychotherapy that includes an exposure-based therapy (with
multiple brief, interrupted exposures to traumatic material), eye movement, and recall
and verbalisation of traumatic memories of an event or events. It therefore combines
multiple theoretical perspectives and techniques, including CBT.
Client wishes to make drastic life change during psychotherapy, how would you manage?
- Review client MS– ensure not due to psychosis mood etc.
- Bets to avoid drastic life changes during the course of psychotherapy
- Ask client not to make decision until feelings and motivation has been addressed during the therapy
- Organise urgent peer review/discussion
- Explore reasons for this decision – transference issues, projection, displacement, splitting, etc. look at the defence mechanisms
- Arrange for joint session with husband/or the person to which the decision applies to exp-lore any issues
Family Therapy
-
Pt brings gift - mx
Continue regular therapy, monitor risk
Monitor countertransference
Discuss meanings of gift with pt: hostility, guilt, gratitude, manipulation
Discuss boundaries
Discuss in supervision
How to give psycho education
Appropriate language and terms
Process of diagnosis and the diagnosis itself, with differentials
Treatment options
Prognosis
Behavioural strategies
